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RESEARCH ARTICLE
Bilateral Idiopathic Carpal Tunnel Syndrome:
Clinical-Functional Characterization and Efficacy
of Two Combined Postoperative Physiotherapeutic
Treatments
Sergio Murilo Georgeto, PhD
1
, Rodrigo Antônio Carvalho Andraus, PhD
2
, Eros de Oliveira Júnior, PhD
3
,
Rubens A da Silva, PhD
4
, Suzy Ngomo, PhD
5
, Karen Barros Parron Fernandes, PhD
6
1
Department of Neurosurgery, Irmandade da Santa Casa de Londrina (ISCAL); Doctoral Program in Rehabilitation Sciences UEL/UNOPAR,
Universidade Pit
agoras UNOPAR,
2
Doctoral Program in Rehabilitation Sciences UEL/UNOPAR, Universidade Pit
agoras UNOPAR,
3
Instituto
Avançado de Ensino, Pesquisa e Tecnologia de Londrina (IAEPETEL) and
6
School of Medicine, Pontifical Catholic University of Parana
(PUCPR), Londrina, PR, Brazil; Département des Sciences de la Santé, Centre Intersectoriel en Santé Durable, Laboratoire de recherche BioNR,
Université du Québec à Chicoutimi (UQAC), Saguenay, Québec, Canada; Instituto de Ensino, Pesquisa e Inovaç˜
ao da Irmandade da Santa
Casa de Londrina (IEPI-ISCAL), Londrina, PR, Brazil and
4
Département des Sciences de la Santé, Centre Intersectoriel en Santé Durable,
Laboratoire de Recherche BioNR, Université du Québec à Chicoutimi (UQAC); Centre Intégré de Santé et Services Sociaux du Saguenay-Lac-
Saint-Jean (CIUSSS SLSJ), Services Spécialisés de Gériatrie –Hôpital de La Baie and
5
Département des Sciences de la Santé, Centre
Intersectoriel en Santé Durable, Laboratoire de recherche BioNR, Université du Québec à Chicoutimi (UQAC), Saguenay, Québec, Canada
Objective: To evaluate the efficacy of combined association instrument myofascial mobilization (IASTM) and
stretching in patients with idiopathic bilateral carpal tunnel syndrome (CTS) operated on one hand and to analyze the
response of the operated (OH) and non-operated (NH) hand according to the sequence of therapies. Research on
these parameters has not yet been found in the literature.
Methods: Randomized controlled crossover study with 43 participants using the objective and subjective outcome var-
iables. Patients were randomly assigned to two groups: starting with stretching followed by IASTM and starting with
IASTM followed by stretching. Then patients underwent surgery on the hand with more severe involvement and physi-
cal therapy rehabilitation was started 30 days after for a period of 4 weeks. After the 1-week interval the participants
who started with stretching were referred to IASTM and vice versa, following the same previous patterns. The outpa-
tient reassessments took place at 3 to 6 months. Crossover ANOVA and effect sizes were used as analysis methods.
Results: Time was the most significant outcome for all variables both during therapies and at 6-month follow-up. Regard-
ing response to the combined therapies between OH and NH, there were differences for both OH and NH, with the greatest
impact on NH for the palmar grip and VAS variables. The treatment sequences were significant for pain on the NH and men-
tal SF-12, suggesting that starting with IASTM followed by stretching had a superior outcome for these outcomes.
Conclusion: The combination of IASTM with stretching, used in the postoperative period of bilateral idiopathic CTS,
proved to be supplementary, with significant results and large effect sizes for most of the outcomes assessed, both
during the time of application of the therapies and in the 6-month follow-up for both hands, and may constitute a viable
therapeutic alternative for this population.
Key words: Carpal tunnel syndrome; Crossover study; Muscle stretching exercises; Myofascial mobilization; Physical
therapy; Surgical decompression
Address for correspondence Sergio Murilo Georgeto, PhD, Av. Bandeirantes, 476, Londrina, PR, Brasil, CEP: 86020-020. Email: georgetosm@gmail.
com; Karen B P Fernandes, R Sen Souza Naves, 441 sala 141, Londrina, PR, Cep: 86010-160. Email: karenparron@gmail.com.
Received 28 October 2022; accepted 19 February 2023
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© 2023 THE AUTHORS.ORTHOPAEDIC SURGERY PUBLISHED BY TIANJIN HOSPITAL AND JOHN WILEY &SONS AUSTRALIA,LTD.
Orthopaedic Surgery 2023;15:1654–1663 •DOI: 10.1111/os.13705
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Introduction
Carpal tunnel syndrome (CTS) is the most common
median nerve compression neuropathy in the adult pop-
ulation worldwide, arising from any pathological condition
that causes decreased cross-sectional area or expansion of
the carpal tunnel components.
1
The incidence of CTS is three to four new cases in
1000 people per year and has been showing an increase in
cases over the last decade.
2
This syndrome affects three
times more women than men, with prevalence between
30 and 40 years for women and between 60 and 80 years
for men, with bilateral involvement in 60% of cases.
3
A
Brazilian study showed similar prevalence to those cited
above.
4
CTS is related to constitutional factors and com-
orbidities. The main constitutional factors are advanced age,
gender, high body mass index, menopause, and pregnancy.
5
Relevant clinical comorbidities are diabetes mellitus, hypo-
thyroidism, obesity and rheumatoid arthritis.
6
If a causative
agent cannot be found, this syndrome is referred to as
idiopathic.
7
The clinical condition is made up of pain, numbness,
8
and tingling in the median nerve (MN) territory in the hand
or arm, which can be associated with weakness and atrophy
of the tenar muscles, causing loss in the hand strength.
2
The
presence of sensory changes restricted to the distribution of
the MN in the hand and Tinel and Phalen’s signs are key
findings in determining the clinical diagnosis.
9
Clinical treatment is encouraged in mild and moderate
CTS.
10
Surgical treatment is indicated in severe cases
11
—the
surgical approach can be done either by open surgery
(OS) or endoscopic surgery (ES).
12,13
There are no statistical
differences in postoperative outcomes between OS and ES
procedures in literature.
14–16
Postoperative physiotherapy has been advocated in the
literature for the rehabilitation process of the operated
hand.
17
However, despite the high prevalence of bilateral
CTS, there are literature controversies on the use of postop-
erative therapies and their benefits, as well as a lack of com-
mon ground on the protocols to be established in
postoperative rehabilitation.
18
Instrument myofascial mobilization (IASTM) and
stretching are one of the methods used for rehabilitative
physiotherapy,
19,20
however, their combined use has never
been employed in the postoperative period of idiopathic
bilateral CTS, as well as the practice of performing these
therapies bilaterally on the entire upper limb, shoulder, cervi-
cal and thoracic region, on the anterior, lateral and posterior
sides is unprecedent.
The present study aims to evaluate the efficacy of two
combined therapies in patients with idiopathic bilateral CTS
submitted to surgery on one hand. It also aimed to evaluate
the response to combined therapies in operated (OH) and
non-operated (NH) hands after unilateral surgical release in
this type of sample.
Methods
This is a prospective, randomized, double-blind, 2 4
crossover sample study (Crossover 2 4). All partici-
pants were recruited by the Neurosurgery team of Irmandade
da Santa Casa de Londrina, in the carpal tunnel outpatient’s
unit, from January 2018 to February 2019. The study was
approved by the ethics committee of Irmandade da Santa
Casa de Londrina under number 3,276,439, registered at
ClinicalTrials.gov (NCT04347746), and the informed consent
form was signed by all participants.
Inclusion criteria for participants were: age of 18 years
or older with idiopathic bilateral CTS, presenting one or
more of the clinical criteria defined by Burton et al.,
2
physi-
cal status I or II by the American Society of Anesthesia
(ASA), normal laboratory test results to exclude associated
pathology (blood count, renal function, glycemic curve, rheu-
matic profile, and thyroid profile), having no upper limb lim-
itations as well as skin lesions that could prevent them from
performing the suggested therapies, and presenting, through
the electroneuromyography (ENMG) exam, indicating severe
impairment in one of the hands, according to Stevens’
criteria.
21
Participants with a history of allergy to the drugs used
in this treatment, drug users, people with psychiatric disor-
ders or intellectual disability (MR), pregnant women,
patients who had received previous treatment with infiltra-
tion of corticosteroids or who had symptoms for less than
6 months were excluded.
Patients underwent surgery on the hand that presented
the most severe degree of involvement on ENMG, but this
degree was bilaterally severe, the more symptomatic hand
was selected. The surgical approach used was CA, with a pal-
mar incision and local anesthesia with a 1% lidocaine solu-
tion, adrenaline 1:100,000 and 8% sodium bicarbonate in a
1:10 ratio, following the precepts described in WALANT.
22
Anesthetic infiltration followed the technique described as
Hole-in-one.
23
All participants were operated on using the
same technique by a single neurosurgeon, without the use of
a splint or restriction for the use of the hand post-surgery.
After 30-day postoperative period participants were
referred to rehabilitation process according to the random-
ized groups. Starting with stretching followed by IASTM
(group S/M) or starting with the IASTM technique followed
by stretching (group M/S).
Study Protocol
The selected participants, both from group S/M and group
M/S, received the same bilateral treatment in the upper
limbs. Static active stretching was performed on six muscle
groups located in the cervical region, shoulder, wrist, and fin-
gers, totaling 22 exercise sequences, in the standing position.
One stretching series was performed for each exercise
sequence, lasting 40 seconds and with a 1-minute rest inter-
val between each muscle group. Stretching was performed
aiming for the greatest possible amplitude to the point of
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BILATERAL IDIOPATHIC CARPAL TUNNEL SYNDROME
discomfort, but not to the point of pain, remaining in the
position for 40 seconds. Supervised stretching was performed
twice a week for 4 weeks, with a total time per session of
approximately 45 minutes.
The IASTM was performed exposing the target region,
without the presence of any cosmetics on the skin. The pro-
tocol consisted in mobilizing the thorax muscles in the ante-
rior and posterior region, shoulder, arm and forearm
muscles, both in the anterior and posterior face, in dorsal,
ventral and lateral decubitus. In myofascial mobilization, up
to five types of instruments (crochets) were used, with
appropriate conformation of opening and inclination for
each muscle group, allowing the best coupling between the
crochet and the portion of myofascial tissue to be mobilized.
The IASTM technique had centripetal direction and was
divided into three successive phases: digital palpation, instru-
mental palpation with crochets and mobilization.
At the end of mobilization with the crochets, a superfi-
cial scraping was added, using the convex part of the cro-
chets, on the insertions of the major pectoral and trapezius
muscles at the level of the sternum and occipital bone
respectively, with a total time per session of approximately
45 minutes.
Assessment Instruments
The outcome analyses were evaluated from objective and
subjective variables, according to guidelines as proposed by
Erickson et al.
24
: (i) the best of three successive measure-
ments, with 30 seconds rest between measurements for
maximum force in isometric contraction of the palmar grip
and digital pinch, using Hydraulic Hand Dynamometer
and Hydraulic Pinch Gauge, respectively (both from
Jamar
®
Patterson Medical, Warrenville, IL, USA) following
its manual for measurement acquisition; (ii) visual analogue
scale (VAS) adapted with the Wong–Baker face scale,
25
the
evaluations of pain intensity were related to the current
moment; and (iii) the impact of STC was evaluated by scores
of the Sensitive and Function domains of the Boston Carpal
Tunnel Questionnaire (Boston Carpal Tunnel Questionnaire-
BCTQ) and scores of the Mental and Physical domains of
the quality of life questionnaire SF-12 (12-Item Short Form
Health Survey).
26
Statistical Analysis
The sample size for a crossover design, with statistical power
of 80%, weighting the hypothesis of loading, typical of these
study designs, was estimated at 15 participants per group.
27
Statistical Package for Social Sciences version 25.0
(IBM, Armonk, NY, USA) and Stata version 15.0 (Stata, Col-
lege Station, TX, USA) software were used, and a 5% signifi-
cance level was set for the applied tests. The ANOVA
crossover models were estimated by Ordinary Least Squared
(OLS), using the pkcross Stata v.15 routine.
The observations from period T0 served as baseline,
that is, the ANOVA crossover models were developed from
the difference results of period T0 (T1 =T1’-T0, …,
T4 =T4’-T0), as indicated by Tudor et al.
28
In addition to the crossover ANOVA, the differences
between treatments were also evaluated only in the first
period to completely exclude the effects of carryover. From
the differences in outcomes at T0 and T1 between the groups
(S/M and M/S), the Mann–Whitney (z) test was used.
This same test was used to compare the scalar variables
of the profile between the sequences in the sample descrip-
tion, and in this section the Fisher’s exact test was used for
the categorical variables. To compare the results between the
operated and non-operated hand and between the T0 and
T4 periods, that is, paired samples, the Wilcoxon (z) test
was used.
After determining the statistical significance of the out-
come variables, the effect size was calculated by Cohen’sd,
with classification based on established criteria.
29
For instru-
ments (i) and (ii), the procedures were developed in the con-
text of the operated hand (OH), and non-operated
hand (NH).
Results
Recruitment and Sample Profile
The study followed the CONSORT guidelines for its comple-
tion. After recruiting 252 patients with bilateral CTS, 45 par-
ticipants met the eligibility criteria, of which two were
excluded from the study for various reasons and two partici-
pants lost follow-up before joining physiotherapy treatment.
Forty-three participants were randomized, however oner par-
ticipant from the M/S group and two from the S/M group
did not complete all the evaluation phases. Therefore, 19 in
the S/M group and 21 in the M/S group remained for final
analysis (T4). The allocation flowchart is shown in Fig. 1.
Table 1presents the main information about the par-
ticipants’profile according to the treatment sequences. In
general, the groups were homogeneous in terms of character-
istics. In the case of the severity of the operated hand, all
cases were considered as severe, according to the research
inclusion criteria.
ANOVA Crossover
Tables 2and 3, in addition to bringing the results of the
crossover ANOVA, also indicate the required descriptions
for replications of crossover studies in meta-analysis, as rec-
ommended by Li et al.
30
Table 2highlights the results for
the objective outcomes (hand pressure strength and digital
pinch) and Table 3highlights the results for the subjective
outcomes (VAS, BCTQ, and SF-12).
In the case of objective measures, we observed an effect
of time for both hand pressure and pinch strength in both
hands (Table 2). Evidence in favor of a treatment effect was
also found for the digital pinch measure (in both hands),
however, as the carryover effect was also shown to be signifi-
cant, the results on the treatment effect are inconclusive. It is
worth noting that the separability measure of treatment and
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BILATERAL IDIOPATHIC CARPAL TUNNEL SYNDROME
carryover (1-Cramer’V) indicates that 50% of the variability
can be individualized, that is, half of the variance is shared
between treatment and carryover. These values refer to all
outcomes.
Regarding subjective measures, the effect of period was
highly significant for all outcomes (Table 3). The effect of
sequence was found to be significant for the VAS of the non-
operated hand and the physical and mental domains of the
SF-12. Unlike the objective measures, in the case of the VAS
of the operated hand and the mental domain of the SF-12,
there was a significant effect of treatment and no effect of
carryover, however, this conclusion should be cautiously
Fig. 1 Sample allocation flowchart.
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BILATERAL IDIOPATHIC CARPAL TUNNEL SYNDROME
interpreted and needs further investigation, as the carryover
effect was marginally significant (P=0.06 and P=0.09
respectively). In the case of the BCTQ sensitive domain both
treatment and carryover were significant.
Effect Size
In addition to the Crossover ANOVA models the Mann–
Whitney and Wilcoxon tests were run as a counter test. At the
same time, we calculated the effect size using Cohen’sd(95%
CI), whose values, when the Mann–Whitney and Wilcoxon
tests were significant, are shown in Table 4.Asdisplayedin
Table 4, all period effects can be considered large, except for
the SF-12 physical domain. In general, there is evidence that
physical therapy acted positively in the improvement of patients
who underwent surgery. This positive effect seems to be shared
by both surgery and physical therapy procedures.
The point estimate of the treatment effect size for the
digital pinch measurement and VAS of the non-operated
hand can be considered large. Generically, IASTM performed
better than stretching for digital pinch and pain reduction in
the unoperated hand. Despite small and intermediate effect
sizes the effect of the sequence was also significant for some
outcomes: (i) VAS of the non-operated hand; (ii) function
domain of the BCTQ; and (iii) SF-12 in both domains. Thus,
there are indications that starting with IASTM leads to a
greater improvement in these items than starting with
stretching for patients who underwent CTS surgery, although
the effect size is not large.
This finding can be viewed in Fig.2(a) and (c), respec-
tively. It can be seen that for almost the same level of the
operated and non-operated hand in the outcomes of grip
strength (≈28) and VAS (≈2) in the fourth period, the
operated hand has a lower level of grip strength (15.1 vs
18.1) and higher VAS score (7.8 vs 6.3) in the baseline period
(i.e., the difference between the fourth period and baseline
period was greater for the operated hand than the non-
operated hand).
Discussion
The present study presented robust results of objective
and subjective measures evaluated the postoperative
rehabilitation of patients with bilateral idiopathic CTS, dem-
onstrating that IASTM and stretching was effective, and the
effect size was considered large for most outcomes.
Crossover ANOVA findings were expressed in terms
of the sequence applied, the treatment, carryover and the
follow-up period (T4-T0).
30
The adoption of a crossover
study model, which used the individual himself, coupled with
analysis of the bilateral data using Crossover ANOVA, which
manages the influence of repeated measures as a result of
bilaterality, produced reliable results for the outcomes
assessed.
31
The groups were evaluated for a number of different
outcomes, and findings were found to be pointwise for both
OH and NH with respect to some variables for sequence and
treatment. However, when checking the results considering
the period, they were significant and with effect sizes consid-
ered large for most outcomes, demonstrating that the combi-
nation between these two techniques was effective both
during their implementation and at 6-month follow-up,
suggesting that these therapies have a supplementary effect.
32
The isolated use of stretching in the postoperative
rehabilitation of CTS in AC with palmar incision was
described by Nathan et al.
33
The authors performed dynamic
stretching at the wrist for 2 weeks and obtained satisfactory
results.
33
Schmid et al.
34
conducted physical therapy
TABLE 1 Sample Profile by Treatment Sequence
Variables Category
Treatment sequence [n (%)]
Total [n =43]
Test
S/M [n =21] M/S [n =22] χ
2
/z P-value
Sex Female 19 (90.5) 21 (95.5) 40 (93.0) 0.410
¥
0.607
Ethnicity White 13 (81.3) 14 (73.7) 27 (77.1) 0.282
¥
0.700
Marital status Married 16 (80.0) 15 (71.4) 31 (75.6) 0.408
¥
0.719
Occupation Housewife 6 (28.6) 11 (52.4) 17 (40.5) 2.471 0.208
Education High school 14 (73.7) 13 (61.9) 27 (67.5) 0.631 0.511
Family income Up to 1.000 BRL 9 (52.9) 14 (66.7) 23 (60.5) 0.741 0.509
BMI Non-normal weight 19 (90.5) 17 (77.3) 36 (83.7) 1.374
¥
0.412
Dominant hand Right 19 (90.5) 20 (90.9) 39 (90.7) 0.002
¥
1.000
Stevens NH Light 6 (28.6) 3 (13.6) 9 (20.9) 5.322
¥
0.070
Moderated 9 (42.9) 5 (22.7) 14 (32.6)
Severe 6 (28.6) 14 (63.6) 20 (46.5)
Age (years) mean SD 50.52 7.86 52.45 12.57 51.51 10.46 0.207 0.836
Symptom time (years) OH mean SD 5.15 4.62 5.62 2.92 5.38 3.83 1.27 0.205
Symptom time (years) NH mean SD 4.68 4.19 4.14 3.18 4.41 3.68 0.345 0.730
Abbreviations: NH =Non-operated hand; SD =Standard Deviation; S =Stretching; M =Miofascial mobilization; BRL =Brazilian Real; BMI =Body Mass Index.
χ
2
/z =Fisher’s exact test (χ
2
) and the Mann–Whitney test (z) [for age and symptom time].; Note: The categories indicated in the table are the most frequent.
¥
Indi-
cates that even with the reclassifications, an expected count of less than five was obtained in two cells
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TABLE 2 Objective Outcomes (Difference to Baseline) from a Two-Treatment, Four-Period Crossover Trial
Outcome
Treatment sequence S/M
(n =81) M/S (n =87)
Treatment period 4[mean (SD)] Effect F(p)
T1 (n =43) T2 (n =43) T3 (n =42) T4 (n =40) Sequence Treatment Carryover Period
Hand grip strength (OH) S/M 4.02 (4.08) 9.14 (5.98) 11.23 (6.12) 13.25 (5.72) 0.58 (p =0.45) 2.08 (p =0.15) 0.70 (p =0.41) 73.23 (p < 0.00)
M/S 5.92 (3.27) 9.91 (4.30) 12.32 (4.57) 13.17 (6.07)
Hand grip strength (NH) S/M 3.49 (1.98) 7.06 (4.21) 9.70 (4.32) 10.32 (4.51) 0.73 (p =0.40) 0.79 (p =0.38) 1.61 (p =0.21) 65.73 (p < 0.00)
M/S 4.91 (3.28) 8.17 (3.90) 10.20 (4.19) 10.67 (5.15)
Tip pinch gauge (OH) S/M 0.51 (0.45) 1.24 (0.57) 1.40 (0.66) 1.59 (0.78) 0.00 (p =0.98) 12.18 (p < 0.00) 8.58 (p < 0.00) 54.38 (p < 0.00)
M/S 0.73 (0.37) 1.17 (0.56) 1.29 (0.61) 1.27 (0.74)
Tip pinch gauge (NH) S/M 0.45 (0.31) 1.17 (0.63) 1.32 (0.68) 1.51 (0.82) 0.24 (p =0.63) 9.54 (p < 0.00) 6.71 (p =0.01) 52.42 (p < 0.00)
M/S 0.75 (0.38) 1.20 (0.56) 1.35 (0.62) 1.33 (0.75)
Abbreviations: 4=Difference; OH =Operated hand; NH =Non-operated hand; T =Period; SD =Standard Deviation; S =Stretching; M =Miofascial mobilization. Effect F(p) refers to Ftest (p-value) of
the effects estimated from Crossover ANOVA.; Note:The values highlighted in bold are significant at 5%
TABLE 3 Subjective Outcomes (Difference to Baseline) From a Two-Treatment, Four-Period Crossover Trial
Outcome
Treatment sequence S/M
(n =81) M/S (n =87)
Treatment period 4[mean (SD)] Effect F(p)
T1 (n =43) T2 (n =43) T3 (n =42) T4 (n =40) Sequence Treatment Carryover Period
VAS (OH) S/M 3.67 (0.80) 5.52 (0.81) 6.00 (0.86) 6.00 (0.88) 0.81 (p =0.37) 11.38 (p < 0.00) 3.56 (p =0.06) 125.59 (p < 0.00)
M/S 3.86 (0.56) 5.14 (0.83) 5.59 (0.73) 5.76 (0.70)
VAS (NH) S/M 2.33 (0.80) 3.57 (0.75) 4.00 (0.79) 4.11 (0.74) 4.56 (p =0.04) 1.10 (p =0.30) 1.08 (p =0.30) 68.93 (p < 0.00)
M/S 3.09 (1.06) 4.18 (1.30) 4.59 (1.22) 4.67 (1.24)
BCTQ (sensitive) S/M 14.81 (5.81) 21.33 (5.70) 23.10 (5.88) 25.16 (6.99) 1.09 (p =0.30) 9.31 (p < 0.00) 6.43 (p =0.01) 90.99 (p < 0.00)
M/S 14.73 (4.71) 19.14 (5.45) 21.14 (4.94) 22.14 (4.74)
BCTQ (function) S/M 7.76 (3.11) 12.10 (3.71) 14.75 (2.75) 16.11 (3.70) 0.34 (p =0.09) 2.41 (p =0.12) 5.38 (p =0.02) 92.65 (p < 0.00)
M/S 6.68 (3.50) 10.50 (3.85) 12.82 (4.08) 13.14 (4.26)
SF-12 (physical) S/M 1.31 (5.05) 1.72 (4.87) 1.22 (5.52) 0.52 (5.58) 5.36 (p =0.03) 0.34 (p =0.56) 2.48 (p =0.12) 5.21 (p < 0.00)
M/S 0.97 (4.07) 3.83 (4.71) 5.20 (4.32) 4.88 (4.26)
SF-12 (mental) S/M 10.63 (7.63) 16.82 (7.74) 20.43 (8.20) 22.26 (8.93) 5.15 (p =0.03) 3.80 (p =0.05) 2.94 (p =0.09) 24.46 (p < 0.00)
M/S 8.22 (4.68) 11.76 (6.56) 14.90 (7.23) 15.48 (7.92)
Abbreviations: 4=Difference; OH =Operated hand; NH =Non-operated hand; T =Period; S =Stretching; M =Miofascial mobilization; VAS =Visual Analogue Scale; BCTQ =Boston Carpal Tunnel Ques-
tionnaire; SF-12 =12-Item Short Form Health Survey. Effect F (p) refers to F test (p-value) of the effects estimated from Crossover.; Note: The values highlighted in bold are significant at 5%
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treatment with tendon mobilization exercises and MN in the
postoperative period of AC with palmar opening. The
authors observed a beneficial effect after a one-week physical
therapy, with a reduction of edema in the MN in the oper-
ated hand indicated by MRI examination.
34
The benefits observed from stretching in CTS may
stem from improving the viscoelastic properties of the mus-
culoskeletal tissue,
35
restoring proprioceptor and nociceptor
dysfunctional patterns at both central and peripheral nervous
system levels,
36
and remodeling the subsynovial connective
tissue (TCSS).
37
The use of myofascial mobilization in postoperative
rehabilitation of CTS has not yet been reported in literature,
although it is indicated in TCSS dysfunctions such as fascia
pain syndromes, low back pain, plantar fasciitis and
myofascial trigger points (Robert
38
). The beneficial effects of
myofascial mobilization on the TCSS would be related to the
following causes: the release of adhesions existing between
the connective tissue and the MN allowing the free gliding of
the MN along the fascia; the biomechanical restructuring
both locally and at a distance recomposing the body’s ten-
sion network; and the stimulation of fibroblast growth that
triggers an increase in collagen synthesis, maturation, and
alignment rebuilding the TCSS.
39–42
The involvement of the TCSS in the pathophysiology
of CTS was recognized by Matsuura et al.
43
The structural
changes in the TCSS that would jeopardize the normal slid-
ing between the NM and the flexor tendons, causing
repeated injury to the NM by displacement of the tendons.
43
This type of injury has been documented in both animal
studies
44
and in a cadaveric model.
45
As such, stretching and IASTM would act as supple-
mentary rather than competitive therapies, justifying, in part,
the good results obtained in their combination in the postop-
erative period of CTS.
19,45,46
In the presence of idiopathic bilateral CTS there is an
option in literature to perform surgery on both hands simul-
taneously
47,48
or to operate on one hand and evaluate the
effect of surgery on OH and NH.
49,50
The results of surgery on NH are conflicting in litera-
ture. Unno et al.
51
evaluated patients with bilateral CTS
operating on only one hand and reported improved hand
NH both immediately postoperatively and at follow-up for
6 months after surgery, regardless of the severity of NH
impairment.
51
According to Agrawal and Southern,
52
the improve-
ment of NH hand in bilateral CTS cases showed spontaneous
recovery in 37% of cases after 6 months of follow-up period.
However, there is disagreement in the literature regarding
the NH hand as shown in the study by Afshar et al.
53
The
authors reported that NH remained unchanged after
6 months of follow-up in a bilateral CTS sample containing
24% NH hands classified as severe according to Stevens’
ENMG criteria.
53
The reasons for the improvement in the NH hand after
performing contralateral surgery may be related to the
decrease in the persistent paresthetic stimulus that deacti-
vates interneurons located in the spinal cord and
brainstem,
54
disinhibiting the sensory pathways (De
55
).
These precepts assume that CTS is a complex neuropathy
with both central and peripheral nervous system involve-
ment. However, there is a need for additional research in
order to clarify in more detail the mechanisms involved in
bilateral CTS.
56
The causes for the obtained results in the OH are still
controversial. According to Bland
57
the reasons for the
improvement observed in the OH cannot be explained only
by the surgical release of the flexor retinaculum. The author
analyzed 32,936 surgical interventions using AC and con-
cluded that 17% of patients had a moderate improvement
TABLE 4 Effect Size by Sequence, Treatment and Period
Outcome Measure
Cohen’sd(IC 95%)
Sequence Treatment Period
Hand grip strength OH ––1.93 (1.40; 2.46)
NH ––2.55 (1.96; 3.14)
Tip pinch gauge OH ––2.68 (2.08; 3.29)
NH –0.86 (1.49; 0.24) 3.08 (2.43; 3.73)
VAS OH ––6.78 (7.92; 5.64)
NH 0.53 (0.23; 0.84) 0.80 (0.18; 1.43) 3.67 (4.39; 2.96)
BCTQ Sensitive ––5.01 (5.91; 4.12)
Function 0.39 (0.70; 0.09) –5.13 (6.03; 4.22)
SF-12 Physical 0.64 (0.95; 0.33) –0.50 (0.06; 0.95)
Mental 0.59 (0.28; 0.90) –2.07 (1.52; 2.61)
Abbreviations: OH =Operated hand; NH =Non-operated hand; VAS =Visual Analogue Scale; BCTQ =Boston Carpal Tunnel Questionnaire; SF-12 =12-Item
Short Form Health Survey.; Note:The cell values indicate that the respective bivariate tests (Mann–Whitney for sequence and treatment, and Wilcoxon for period)
were significant at the 5% level. For the sequence we considered all periods (i.e., M/S [n =87] and S/M [n =81]). For treatment we considered the baseline dif-
ference of the outcome in the first period between the groups (i.e., M [n =22] and S [n =21]). And to assess the effect of period we took the endpoint value at
baseline and the endpoint value at the fourth period as paired samples (i.e., n =40)
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while in 8% of cases there was a worsening of symptoms.
Therefore, to think of the improvement obtained in the OH
as resulting from the pressure decrease inside the carpal tun-
nel due to the surgical release of the transverse carpal liga-
ment may not be a reality, as this did not occur in 25% of
the operated cases.
57
In a recent systematic review and meta-analysis,
Georgeto et al.,
58
present favorable evidence of clinical
and surgical treatments, as they potentially improve
symptom severity, functional status and pain intensity in
patients with bilateral CTS during periods of 1- and
3-month follow-up.
A B
D E
C
Fig. 2 Outcomes means by period. VAS =Visual Analogue Scale; BCTQ =Boston Carpal Tunnel Questionnaire; SF-12 =12-Item Short Form Health
Survey. The graphs illustrate the positive development of the outcomes throughout physiotherapy, supported by the statistical analyses carried outin
the research and the effect sizes shown in Table 4. The values refer to the original measures and not to the baseline differences, since the baseline
differences were evidenced in Tables 2and 3.
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Thus, in order to improve the results of both OH and
NH, the use of post-surgical physiotherapy has been rec-
ommended in recent literature. However, despite the exis-
tence of several protocols for postoperative rehabilitation for
CTS, their implementation remains a controversial point in
literature and is not supported by national medical insurance
in some countries, such as France.
The reasons for divergences regarding the acceptance
of physiotherapy in the postoperative period of CTS are due,
in part, to the limitations found in literature when
addressing the use of therapies in the post-surgical rehabili-
tation of CTS, such as: the scarcity of studies containing
exclusive samples of patients with idiopathic bilateral CTS,
since these cases present clinical peculiarities that distinguish
them from unilateral CTS;
59
the low quality of evidence on
the benefits of different types of rehabilitation arising from
problems in the allocation and concealment of bilateral CTS
patients in randomized studies;
60
the presence of over-
estimated results due to the use of statistical tests that disre-
gard the repetition of data arising from bilaterality;
61
the
absence of a standardization of rehabilitation programs
worldwide
62
and the lack of a gold standard instrument for
assessing the results of the therapies employed that entails
the use of many different outcome measures, making it diffi-
cult to compare the findings between studies.
63
Strength and Limitations
We believe that our study can contribute to these questions,
because we proceeded with an unpublished RCT in the liter-
ature, with a sample containing exclusively patients with idi-
opathic bilateral CTS, we evaluated the combined results of
surgery and physical therapy in this sample, both during the
treatment period, as well 6- months follow-up, with several
outcome measures, and the statistical method employed con-
trolled by patients with bilateral CTS, avoiding that the
results of the outcome measures were overestimated.
The limitations of this study were that it was carried
out in a single center, which jeopardized its external validity,
and the absence of a control group without physical therapy
treatment in order to compare the results obtained in the
evaluation periods, and the design of the experiment did not
allow for the separation of the effects of surgery and physical
therapy.
However, further studies are required in order to over-
come the deficiencies in randomized clinical trials using sam-
ples containing only bilateral idiopathic CTS patients, with
allocation being made per participant and not per wrist,
appropriate statistical analyses in view of the data repetition
due to bilaterality, and the attempt to establish a pattern of
therapies, as well as the measures to evaluate the results so as
to produce reliable evidence and allow the comparison
between the studies.
Conclusion
The current study presented robust results of objective and
subjective measures in the post-surgical rehabilitation of
patients with idiopathic bilateral CTS, demonstrating that
the proposed therapeutic model was effective for all the vari-
ables evaluated, and the effect size was considered large for
most of the outcomes. This research showed robust results
for the period, demonstrating that the therapeutic combina-
tion used in the postoperative period of bilateral idiopathic
CTS brought good results during its application, as well as
these were maintained in the 6-month follow-up. An
improvement of both OH and NH was also noted from a
functional and sensitivity point of view.
Although the beneficial effects of physical therapy and
surgery are difficult to dissociate, the outcome performance
over time shows that surgery followed by the proposed phys-
ical therapy treatments or some interaction between them
has positive effects on operated and unoperated hands in
patients with idiopathic CTS bilateral, may be a valid strategy
used for this population.
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